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What You Need to Know about Venous Thromboembolism By Bill Pruitt, RRT, AE-C, CPFT, MBA and Robin Lawson, RN, DNP Nursing2009, April 2009 2.3 ANCC contact.

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Presentation on theme: "What You Need to Know about Venous Thromboembolism By Bill Pruitt, RRT, AE-C, CPFT, MBA and Robin Lawson, RN, DNP Nursing2009, April 2009 2.3 ANCC contact."— Presentation transcript:

1 What You Need to Know about Venous Thromboembolism By Bill Pruitt, RRT, AE-C, CPFT, MBA and Robin Lawson, RN, DNP Nursing2009, April ANCC contact hours Online: © 2009 by Lippincott Williams & Wilkins. All world rights reserved.

2 What is venous thromboembolism (VTE)?  An occlusion in a vein caused by a thrombus (most common)  An embolus of an air bubble, fat droplets, amniotic fluid, clumps of parasites, tumor cells (less common)  In I.V. drug users, a foreign substance such as talc can lead to VTE

3 Where does VTE occur?  Typically in leg veins  2% to 3% occur in arms  Pulmonary embolism can occur when part of a deep vein thrombosis (DVT) breaks loose and travels through the right side of the heart into pulmonary artery

4 Pulmonary embolism (PE)  PE occludes blood flow to part of the lung and impairs gas exchange  Affected portion of lung becomes necrotic and impairs oxygen delivery to other body tissues  90% of all PEs come from thrombi in the popliteal vein and larger veins above it

5 What happens in DVT and PE  When DVT obstructs venous circulation in a leg, collateral circulation may develop rapidly  Patient may have few signs and symptoms; when they develop, are related to local inflammation and local tissue ischemia as well as degree of venous outflow obstruction

6 What happens in DVT and PE  Complications of DVT include venous valvular damage, chronic venous insufficiency (chronic pain, swelling, cramping, skin discoloration, ulceration in affected limb), PE  PE obstructs blood flow in pulmonary arterial system

7 What happens in DVT and PE  Pathologic changes depend on degree of obstruction and patient’s condition  If blood flow is obstructed in gas exchange areas of lung (alveoli and respiratory bronchioles), you’ll see V/Q mismatch and increased physiologic dead space ventilation

8 What happens in DVT and PE  Extensive PE causes large area of dead space ventilation, imposing increased work on right ventricle as a result of obstructed right ventricular outflow and pulmonary vasoconstriction from release of vasoactive mediators

9 What happens in DVT and PE  Increased right ventricular afterload results in right ventricular hypertrophy and decreased right ventricular ejection fraction. Ventricle becomes ischemic and may eventually progress to right ventricular failure

10 Risk factors  Hereditary: deficiency in antithrombin, protein C, protein S, or plasminogen  Acquired: surgery, trauma, advanced age, cancer, reduced mobility, smoking, use of oral contraceptives, pregnancy

11 Assessing a patient’s VTE risk  Scoring systems based on patient’s clinical characteristics can estimate patient’s likelihood of developing VTE  Wells prediction rule for DVT, Wells and Geneva prediction rules for PE provide probability ranking for VTE based on history of DVT or PE, cancer, recent surgery/immobilization, age, heart rate

12 Assessing a patient’s VTE risk  Based on type and number of risk factors, patient’s level of risk can be classified as low, moderate, or high as stipulated in 2008 ACCP guidelines  Appropriate prophylactic treatment can start based on ACCP recommendations. Risk assessment is ideally incorporated into initial assessment form

13 Comparing VTE Risk Level of risk  Low: mobile patients undergoing minor surgery; medical patients who are fully mobile  Moderate: patients undergoing general surgery or open gynecologic or urologic surgery; medical patients who are sick or on bed rest

14 Comparing VTE Risk Level of risk  High: patients undergoing hip or knee arthroplasty or hip fracture surgery; patients with major trauma or spinal cord injury

15 Comparing VTE Risk Risk of DVT if no prophylaxis is given  Low: less than 10%  Moderate: 10% to 40%  Moderate plus high bleeding risk: 10% to 40%  High: 40% to 80%  High plus high bleeding risk: 40% to 80%

16 Comparing VTE Risk Suggested prophylaxis  Low: no specific prophylaxis; early and aggressive ambulation  Moderate: low-molecular-weight heparin (LMWH) at recommended doses, low- dose unfractionated heparin 2 or 3 times/day, or fondaparinux

17 Comparing VTE Risk  Moderate plus high bleeding risk: mechanical prophylaxis with intermittent pneumatic compression,venous foot pump, graduated compression stockings  High: LMWH at recommended doses, fondaparinux, oral vitamin K antagonists to maintain INR between 2 and 3  High, plus high bleeding risk: mechanical prophylaxis as above

18 Recognizing VTE  Patient with DVT: edema, pain, warmth in one leg, venous stasis ulcers, venous varicosities, venous insufficiency  Patient with PE: dyspnea, hemoptysis, cough, wheezes, tachypnea, pulmonary crackles, chest pain, palpitations, tachycardia, lightheadedness; suspect massive PE with sudden hypotension, syncope, severe hypoxemia, cardiac arrest

19 Diagnosing VTE  Based on patient’s risk factors, physical assessment findings, diagnostic study results  Physical assessment for DVT: examine patient’s legs, noting erythema, tenderness, pain; palpation could dislodge and cause PE

20 Diagnosing VTE  D-dimer: normal value less than 500 ng/mL; if high, needs duplex ultrasound  Duplex ultrasound: two-dimensional ultrasound with Doppler; provides vein images, blood flow measurements; loses accuracy in calf vein  Contrast venography: gold standard; invasive with potential complications

21 Is it PE?  Diagnostic testing aimed at: - confirming condition - defining severity - ruling out conditions that mimic PE (pneumonia, myocardial infarction)  If massive PE suspected, treatment takes priority over testing

22 Diagnosing PE  Chest X-ray: helps rule out other causes  ECG: useful for ruling out cardiac causes; may show ST, T wave changes  Arterial blood gases: will show ventilation perfusion mismatch

23 Diagnosing PE  D-dimer: can help rule out PE  Spiral computed tomography pulmonary angiography; can help confirm diagnosis of PE and rule out other causes

24 Preventing VTE after surgery  Risk depends on type of surgery, presence of other risk factors  Procedures with prolonged immobility are at highest risk: orthopedic, neurosurgery, major vascular surgery, major abdominal or pelvic surgery

25 Preventing VTE after surgery  Latest guidelines from ACCP recommend all hospitals develop formal prevention strategy to include: - computerized decision support - preprinted or standing orders - regular audits to monitor adherence  Guidelines recommend against using aspirin alone and early ambulation in low-risk general surgery patients

26 Treating VTE  Anticoagulants, warm compresses, leg elevation are first-line treatment  Oxygen, ventilation, I.V. fluids, fibrinolytics may be ordered for PE  Vena cava filter may stop traveling thrombi  Embolectomy: for patients with massive PE who don’t respond to fibrinolytics

27 Inferior vena cava (IVC) filter  Some newer filters are called retrievable or optional filters  Can be retrieved after a period or left in permanently  Recommended for patients with documented VTE who have difficulty receiving full-dose anticoagulation

28 Prevention  Hospitalized patients should be routinely assessed for VTE risk  Measure and use graduated compression stockings correctly  Make sure pneumatic compression devices function properly

29 Prevention  Explain importance of these devices to patient  Encourage early ambulation after surgery  Surgical patients on unfractionated heparin will need baseline aPTT, hematocrit, and platelet counts

30 Prevention  If long-term anticoagulation is needed, warfarin will be started for 4 to 5 days before heparin is discontinued  Heparin discontinued when INR is in therapeutic range (2.0 to 3.0) on two consecutive measurements 24 hrs apart  Monitor patient for signs of bleeding

31 Educating your patient  Teach patient risk factors for DVT  Teach preventive measures  Instruct patient to call HCP if signs and symptoms of DVT develop

32 Warfarin therapy patient education  Eat limited foods high in vitamin K  Keep blood work appointments  Check with HCP or pharmacist before taking vitamin supplements

33 Warfarin therapy patient education  Limit alcohol intake  Alert HCP about anticoagulant therapy before undergoing medical procedures  Protect from injury (soft toothbrushes, electric razors) due to bleeding/bruising

34 Warfarin therapy patient education  Stop smoking, lose weight, drink lots of fluids  Women should not use oral contraceptives if history of DVT/PE

35 Travel  Long air flights, car rides linked to DVT/PE  ACCP recommends anyone sitting for more than 8 hours avoid constrictive clothing and stay hydrated  For patients at high risk for DVT, wear graduated compression stockings or receive single dose of LMWH before departure


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